Strategy for the management of acute postoperative pain in day surgery centres in Spain. DUCMA 2.0. project.

INTRODUCTION: Adequate treatment of acute postoperative pain is one of the quality requirements in ambulatory surgery and its suboptimal management is associated with delayed discharge, unplanned admissions and late admissions after home discharge. The aim of the present study was to learn about the organizational strategy for the management of postoperative pain in ambulatory surgery units (ASU) in Spain. METHODS: A cross-sectional, multicenter study was carried out based on an electronic survey on aspects related to the management of acute postoperative pain in different ASUs in our country. RESULTS: We recruited 133 ASUs of which 85 responded to the questions on the management of postoperative pain. Of the ASUs that responded, 80% had specific protocols for pain management and 37.6% provided preoperative information on the analgesic plan. The assessment of postoperative pain is carried out in 88.2% of the ASUs in the facility and only 56.5% at home. All ASUs use multimodal analgesia protocols; however, 68.2% report the use of opioids for the treatment of moderate to severe pain. Home invasive analgesia strategies are minimally used by the surveyed ASUs. CONCLUSIONS: The DUCMA study highlights that the practice of pain treatment in day surgery remains a challenge in our country and is not always in agreement with national guidelines. The results suggest the need to establish strategies to improve clinical practice and homogenize pain management in ambulatory surgery.

Deceased donor kidney procurement: Systematic review of the surgical technique.

INTRODUCTION: Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation. OBJECTIVES: Review of the available literature on kidney procurement procedure. MATERIAL AND METHODS: Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish. RESULTS: Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time. CONCLUSIONS: Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.

Pielolitotomía laparoscópica en riñón ectópico pélvico: informe de un caso y revisión de la literatura / Laparoscopic pyelolithotomy in pelvic ectopic kidney: Case report and literature review

Introducción: Los riñones pélvicos son una malformación congénita poco frecuente, pero con una tasa de complicaciones no despreciable, entre ellas el desarrollo de litiasis renales. Su manejo quirúrgico puede resultar complejo. El objetivo de este trabajo fue realizar una revisión de la literatura disponible sobre el tratamiento de la litiasis en riñones ectópicos.Material y métodosDescripción de un caso de pielolitotomía laparoscópica transperitoneal para el tratamiento de litiasis calicial inferior en riñón pélvico derecho. Se realizó una revisión de la literatura mediante PubMed. Se buscaron los siguientes términos: «pelvic ectopic kidney», « ureterorenoscopy», «extracorporeal lithotripsy», «NLPC», «pyelolithotomy». Se incluyeron artículos originales, metaanálisis, revisiones e informes de casos.ResultadosSe excluyeron 130 artículos por título o duplicación. Se evaluaron 62 resúmenes y 50 artículos de texto completo. La tasa libre de cálculos fue del 75% (LEOCH), 85% (URS-f), 85-90% (NLPC) y 100% (pielolitotomía laparoscópica).ConclusiónFactores como el tamaño de la litiasis, densidad y localización de la misma, así como las alteraciones anatómicas del tracto urinario superior, influyen en la elección de la vía de abordaje terapéutica (retrógrada, percutánea y/ o laparoscópica/robótica). (AU)

Introduction: Pelvic kidney is a rare congenital anomaly. The ectopic kidney is more susceptible to developing lithiasis. The management of this type of lithiasis is a challenge. The objective of this paper was to conduct a review of available literature on the treatment of stone in ectopic kidney.Material and methodsDescription of a case of transperitoneal laparoscopic pyelolithotomy for the treatment of inferior calyceal lithiasis in a right pelvic kidney. A literature review was performed by using Pubmed. The following terms and combination terms were searched: «pelvic ectopic kidney», «ureterorenoscopy», «extracorporeal lithotripsy», «PCNL», «pyelolithotomy». We included original articles, meta-analysis, review and case reports.Results130 articles were excluded by title or duplication. 62 abstracts articles and them 50 full text articles were evaluated. Stone free rate were 75% (SLW), 85% (URSf), 85-90% (PCNL) and 100% (laparoscopic pyelolithotomy). The literature on treatment on pelvic kidney is poor.ConclusionFactors such stone size, density and location, and upper urinary tract abnormalities, influence the choice of therapeutic approach (retrograde, percutaneous and/or laparoscopic/robotic). Laparoscopic pyelolithotomy is a safe and minimally invasive treatment option for large kidney stones with unfavorable anatomy for the endoscopic approach. (AU)

Challenges in quantification of photocatalytic NO2 abatement effectiveness under real world exposure conditions illustrated by a case study.

Health risks due to NO2 exposure commonly exceed acceptable levels in modern societies. Among the measures to reduce such risks, photocatalytic materials present a promising technology. However, while the pollutant remediation of such materials has been extensively validated in laboratory studies, the performance under real world environmental exposure conditions is still subject to controversy. Indeed, a comparison of available in-situ monitoring studies manifests non-conclusive and highly scattered results regarding the photocatalytic effectiveness observed. The reasons for this behaviour must be carefully explored in order to prevent non-efficient photocatalytic applications from being put into practice on a larger scale. This paper presents a comprehensive large-scale study for assessing the photocatalytic NO2 remediation by active pavements in a street of Madrid (Spain), comprising different in-situ monitoring techniques. The discussion is enriched by relating the obtained results to those of other large-scale studies. The discrepancies between these results may be traced back to different circumstances, among them the distance between the active pavement and the pollutant concentration sampling inlet, as well as to significant site-specific and time-dependent variations of pollutant concentrations and climatic parameters. Under due consideration of these influences, for materials with relatively high initial effectiveness, it was concluded that in most such applications, the average NO2 removal effectiveness, if evaluated at a typical inlet height of Air Quality Stations (3 m), will not exceed a value of 4% (averaged over a sufficiently large number of measurement points in the area of application and a sustained amount of time, i.e. several months). When considering more realistic human exposure conditions (lower heights and daytime), it might be justified to assume somewhat higher average effectiveness.

NOx removal efficiency of urban photocatalytic pavements at pilot scale.

Photocatalytic technology implemented in construction materials is a promising solution to contribute to alleviate air quality issues found in big cities. Photocatalysis has been proved able to mineralise most harmful contaminants. However, important problems associated with monitoring the efficiency of these solutions under real conditions still remain, including the lack of affordable analytical tools to measure NOx concentrations with enough accuracy. In this work, two pilot scale demonstration platforms were built at two different locations to assess the photocatalytic NOX removal efficiency of ten selected materials exposed outdoors for AQmesh low-cost sensor PODs were used to measure ground-level to measure NO and NO2 concentrations during nearly one year. The pollutant removal efficiency of the materials was then calculated based on a comparison with simultaneously concentration measurements carried-out on reference, non-active materials. It was found that the NO2 removal efficiency presented large variations across the seasons, with maxima during the warmer months, while NO efficiencies were comparatively steadier. Statistical analysis delivered evidence that the efficiencies significantly depend on different meteorological variables (irradiance and relative humidity) besides NO, NO2 ambient concentrations. Lower efficiencies were observed for higher concentration levels and vice versa. The influence of water vapour could be related to two different effects: a short-term contribution by the instantaneous air humidity and a long-term component associated with the hygroscopic state of the material. The contribution of wind to the pollutant removal efficiencies was principally related to the humidity of air masses moving above the location and to the advection of pollutants from specific emission sources.

Acute predictors for mortality after severe TBI in Spain: Gender differences and clinical data.

OBJECTIVE: The main objective of this study is to determine whether gender affects global mortality and functional outcome after severe traumatic brain injury (TBI). METHODS: This retrospective cohort study included 629 patients with severe TBI (14.9% female) admitted to the ICU of a university hospital. Patients were split into gender groups to study potential differences in global mortality and functional outcome at ICU discharge and 6 months post-trauma using the GOS. The following variables were analysed: age, intracranial injury, injury mechanism, injury severity, factors contributing to secondary brain injury, monitoring level, treatment, complications, length of stay in the ICU and cause of death. RESULTS: No differences were found between gender groups in neuromonitoring level or surgical procedures. Women had higher APACHE II scores, a higher incidence of pre-hospital hypotension, anaemia and transfusion and higher mortality rates in the ICU (OR = 1.74; 95% CI = 1.09-2.77) and 6 months post-trauma (OR = 1.65; 95% CI = 1.02-2.67). There were no significant differences in functional outcome at ICU discharge or 6 months post-injury. The multivariate analysis did not show gender as an independent predictive factor in mortality after severe TBI. CONCLUSION: In this study, gender was not found to be an independent predictor for poorer outcome after severe TBI.

[Radioguided surgery in neuroendocrine tumors. A review of the literature]. / Cirugía radioguiada de tumores neuroendocrinos. Revisión de la literatura.

Radioguided surgery can be a useful technique in the localization of neuroendocrine tumors. It detects more and smaller lesions compared to pre-surgical imaging and intraoperative digital palpation by the surgeon. It detects residual lesions and also indicates the shortest access route to the lesion. Nevertheless, its use has not become widespread because of technical difficulties. There is a limited number of published series, a lack of standardized protocol because of the great variability regarding type of radiopharmaceutical, dose of radiotracer, timing between injection and surgery. In this paper, we review these issues, describing the experience of different authors in diverse tumors.

Ultrasonografía doppler transcraneal urgente: utilidad predictiva del vasoespasmo sintomático en la hemorragia subaracnoidea espontánea en pacientes con buena situación neurológica / Emergency transcranial doppler ultrasound: predictive value for the development of symptomatic vasospasm in spontaneous subarachnoid hemorrhage in patients in good neurological condition

Objetivo: Establecer el valor predictivo, para desarrollar deterioro neurológico tardío de origen isquémico (DNI), de un estudio doppler transcraneal (DTC) en pacientes con hemorragia subaracnoidea espontánea (HSA) en buena situación neurológica. Diseño: Estudio descriptivo-observacional desarrollado durante 3 años. Ámbito: Cuidados Críticos y Urgencias. Pacientes: Se incluyeron de forma consecutiva aquellos pacientes con HSA en buena situación neurológica (Hunt-Hess I-III). Variables de Interés: DNI (disminución en 2 puntos del GCS o déficit focal), velocidad media (VM) en arterias cerebrales medias, índice de Lindegaard (IL). Se consideró patrón sonográfico de vasoespasmo (PSV) cuando la VM fue>120cm/s y existía un IL>3. Resultados: La media de edad de los 122 pacientes fue de 54,1±13,7 años. El 57,3% eran mujeres. Se detectaron 24 pacientes con PSV (19,7%) encontrándose VM elevadas en 38 pacientes (31,1%). 21 pacientes desarrollaron DNI (VM 183+/-49cm/s), todos presentaron PSV. En los pacientes con DNI se detectó un aumento de VM de 22+/-5cm/s/24h durante los 3 primeros días. Al comparar aquellos pacientes que no presentaron VM elevadas (85 pacientes/VM 67+/-16,6cm/s) con respecto a los que desarrollaron DNI encontramos diferencias en las VM (p<0,001) y en el ΔVM/24h (8,30+/-4,5cm/s Vs 22+/-5cm/s) durante los 3 primeros días (p=0,009). Mediante curvas ROC, se fijó que el ΔVM/día de 21cm/s (p<0,001), era el que mejor predecía el DNI. Conclusión: Durante los 3 primeros días un incremento en la VM de 21cm/s/24h se asoció con el desarrollo de vasoespamo sintomático. El DTC es una herramienta útil para la detección de aquellos pacientes con HSA en riesgo de desarrollar DNI (AU)

Purpose: To examine the predictive value of an early transcranial Doppler ultrasound (TCD) study performed in the emergency department in patients with spontaneous subarachoniod hemorrhage (SAH) in good neurological condition, in order to know which patients are at high risk of developing delayed cerebral ischemia (DCI). Design: A descriptive observational study was carried out involving a period of 3 years. Setting: Critical Care and Emergency Department. Patients: The study consecutively included patients with SAH of grade I-III on the Hunt and Hess scale. Variables of Interest: DCI (decrease of 2 points in GCS or focal deficit), Mean Velocity (MV) of middle cerebral arteries (MCA), Lindegaard Index (IL). Sonographic vasospasm pattern (SVP) was considered if MCA-MV>120cm/sc and IL>3. Results: The mean age of the 122 patients was 54.1±13.7 years; 57.3% were women. SVP was detected in 24 patients (19.7%), although high velocities patterns (HVP) were present in 38 patients (31.1%). DCI developed in 21 patients (MV183+/-49cm/sc), all with previous SVP. In this group MV increased 22+/-5cm/sc/day during the first 3 days. The group without HVP (84 patients/MV of 67+/-16.6cm/sc), compared with DCI group, showed differences in highest MV (p<0.001), and also ΔMV/day (8.30+/-4,5cm/sc Vs 22+/-5cm/sc) during the first 3 days (p=0.009). In our series, ROC analysis selected the best cut-off value for ΔMV/day as 21cm/sc (p<0.001). Conclusion: During the first 3 days, an increase of 21cm/s/24h in MCA-MV was associated with the development of symptomatic vasospasm. TCD is a useful tool for the early detection of patients at risk of DCI after SAH (AU=

[Emergency transcranial doppler ultrasound: predictive value for the development of symptomatic vasospasm in spontaneous subarachnoid hemorrhage in patients in good neurological condition]. / Ultrasonografía doppler transcraneal urgente: utilidad predictiva del vasoespasmo sintomático en la hemorragia subaracnoidea espontánea en pacientes con buena situación neurológica.

PURPOSE: To examine the predictive value of an early transcranial Doppler ultrasound (TCD) study performed in the emergency department in patients with spontaneous subarachoniod hemorrhage (SAH) in good neurological condition, in order to know which patients are at high risk of developing delayed cerebral ischemia (DCI). DESIGN: A descriptive observational study was carried out involving a period of 3 years. SETTING: Critical Care and Emergency Department. PATIENTS: The study consecutively included patients with SAH of grade I-III on the Hunt and Hess scale. VARIABLES OF INTEREST: DCI (decrease of 2 points in GCS or focal deficit), Mean Velocity (MV) of middle cerebral arteries (MCA), Lindegaard Index (IL). Sonographic vasospasm pattern (SVP) was considered if MCA-MV>120cm/sc and IL>3. RESULTS: The mean age of the 122 patients was 54.1±13.7 years; 57.3% were women. SVP was detected in 24 patients (19.7%), although high velocities patterns (HVP) were present in 38 patients (31.1%). DCI developed in 21 patients (MV183+/-49cm/sc), all with previous SVP. In this group MV increased 22+/-5cm/sc/day during the first 3 days. The group without HVP (84 patients/MV of 67+/-16.6cm/sc), compared with DCI group, showed differences in highest MV (p<0.001), and also ΔMV/day (8.30+/-4,5cm/sc Vs 22+/-5cm/sc) during the first 3 days (p=0.009). In our series, ROC analysis selected the best cut-off value for ΔMV/day as 21cm/sc (p<0.001). CONCLUSION: During the first 3 days, an increase of 21cm/s/24h in MCA-MV was associated with the development of symptomatic vasospasm. TCD is a useful tool for the early detection of patients at risk of DCI after SAH.

[Assessment of hypothalamo-pituitary axis in early phase of severe cranioencephalic brain injury]. / Valoración del eje hipotálamo-hipofisario en la fase precoz del traumatismo craneoencefálico grave.

OBJECTIVE: To assess early pituitary function in a sequential cohort of critical care patients after severe traumatic brain injury (TBI). DESIGN: This was a prospective observational study. The pituitary function was always tested on the third day after TBI. SETTING: Neurocritical intensive care unit (ICU) in a University hospital. PATIENTS: A total of 136 adult patients with severe TBI (range, 16-65 years) enrolled over a 2 year and 9 month period having a stay in the ICU treated than 48 hours. INTERVENTION: None. MEASUREMENTS AND DATA COLLECTED: The following data were recorded within the first 72 hours after injury: demographic variables, injury severity, neuromonitoring data, systemic secondary brain insults, use of vasoactive drugs and type of TBI according to the computerized tomography (CT) scan findings. Pituitary function was evaluated by measurement of both the pituitary and target organ hormones, with the exception of the somatotrophic function, which was assessed by measurement of basal serum values of insulin-like growth factor-I (IGF-I). RESULTS: Pituitary dysfunction was observed in 101 patients (74.2%). Seventy-nine patients (58%) had impairment of only one pituitary axis, the axes being affected as follows: gonadotropic 63.7% (87 patients), thyrotropic 8.8% (12 patients) and corticotropic 0.7% (1 patient). Low IGF-1 plasmatic levels in accordance to the patient's age were observed in 90 patients (66.7%). However, only 26 of them had a value below 90 ng/ml. CONCLUSIONS: Our data show that pituitary dysfunction occurs early and with high frequency after severe TBI, but the real significance of these findings still needs to be elucidated.

Valoración del eje hipotálamo-hipofisario en la fase precoz del traumatismo craneoencefálico grave / Assessment of hypothalamo-pituitary axis in early phase of severe cranioencephalic brain injury

Objetivo. Analizar las características de la función hipofisaria en la fase inicial de pacientes críticos con traumatismo craneoencefálico grave (TCEG). Diseño. Estudio observacional, prospectivo. La función hipofisaria se evaluó siempre el tercer día tras el TCEG. Ámbito. Unidad de cuidados intensivos (UCI) neurotraumatológica de un hospital universitario. Pacientes. Se incluyó a 136 pacientes con TCEG (intervalo, 16-65 años), durante un período de 2 años y 9 meses y estancia en UCI mayor de 48 h. Intervención. Ninguna. Medidas y datos recopilados. Se recogieron durante las primeras 72 h tras el traumatismo: variables demográficas, severidad de la lesión, parámetros de neuromonitorización, lesiones cerebrales secundarias, uso de fármacos vasoactivos y el tipo de traumatismo craneoencefálico (TCE) acorde a los hallazgos encontrados en la tomografía computarizada (TC). La evaluación de la función hipofisaria se determinó por medición de hormonas hipofisarias y las de los órganos diana, con la excepción de la función somatotropa, que se evaluó midiendo las concentraciones séri- cas basales de insulin-like growth factor-1 (IGF-1). Resultados. Se observó disfunción hipofisaria en 101 (74,2%) pacientes; 79 (58%) pacientes tenían afectado solamente un eje hipofisario, la afectación de ejes es la siguiente: gonadotropo, el 63,7% (87 pacientes); tirotropo, el 8,8% (12 pacientes), y corticotropo, el 0,7% (1 paciente). Se observaron concentraciones plasmáticas bajas de IGF-1 acorde a la edad en 90 (66,7%) pacientes, aunque sólo 26 de ellos mostraron un valor menor de 90 ng/ml. Conclusiones. Nuestros datos muestran que la disfunción hipofisaria ocurre precozmente y con gran frecuencia tras un TCEG, aunque el significado real de estos hallazgos están aún por determinar

Objective. To assess early pituitary function in asequential cohort of critical care patients after severetraumatic brain injury (TBI).Design. This was a prospective observationalstudy. The pituitary function was always tested onthe third day after TBI.Setting. Neurocritical intensive care unit (ICU)in a University hospital.Patients. A total of 136 adult patients with severeTBI (range, 16-65 years) enrolled over a 2year and 9 month period having a stay in the ICUtreated than 48 hours.Intervention. None.Measurements and data collected. The followingdata were recorded within the first 72 hoursafter injury: demographic variables, injury severity,neuromonitoring data, systemic secondarybrain insults, use of vasoactive drugs and type ofTBI according to the computerized tomography (CT) scan findings. Pituitary function was evaluatedby measurement of both the pituitary and targetorgan hormones, with the exception of the somatotrophicfunction, which was assessed bymeasurement of basal serum values of insulinlikegrowth factor-I (IGF-I).Results. Pituitary dysfunction was observed in101 patients (74.2%). Seventy-nine patients (58%)had impairment of only one pituitary axis, the axesbeing affected as follows: gonadotropic 63.7%(87 patients), thyrotropic 8.8% (12 patients) andcorticotropic 0.7% (1 patient). Low IGF-1 plasmaticlevels in accordance to the patient’s age wereobserved in 90 patients (66.7%). However, only 26of them had a value below 90 ng/ml.Conclusions. Our data show that pituitary dysfunctionoccurs early and with high frequency aftersevere TBI, but the real significance of thesefindings still needs to be elucidated

Cognitive deterioration due to GH deficiency in patients with traumatic brain injury: a preliminary report.

PRIMARY OBJECTIVE: To determine whether cognitive and behavioural disorders observed in TBI patients are due to hormonal deficits or to the brain injury itself. RESEARCH DESIGN: Transversal, between-group design. METHODS AND PROCEDURES: Studied 22 severe TBI patients (GCS < 8): 11 had isolated GH deficiency and 11 did not. Prepared detailed clinical reports on patients and performed physical examinations, standard biochemical and full blood count analysis. Patients underwent neuropsychological assessment and hormonal evaluation 6 months after TBI diagnosis. RESULTS: TBI patients with GH deficiency show greater deficits in attention, executive functioning, memory and emotion than those without GH deficiency. CONCLUSIONS: Results show GH-related cognitive impairment in patients who develop GH deficiency after TBI and suggest that treatment of GH deficiency would improve cognition. The clinical importance of these findings should be established to better understand the nature, magnitude and meaning of GH-related cognitive impairment in patients who develop GH deficiency after TBI.

Estudio por congelación del ganglio centinela en carcinoma de mama / No disponible

A pesar de que el estudio del ganglio centinela constituyeya un procedimiento de rutina en la estadificación del cáncerde mama, todavía no existe consenso acerca de cuál es el protocolomás eficiente para su estudio histopatológico.El objetivo fundamental de este estudio es describir nuestroprotocolo para el estudio histopatológico del ganglio centinela(GC), comparando los resultados del mismo cuando se realizaintraoperatoriamente o diferido y justificar la inclusión de la citoqueratinacomo parte necesaria del protocolo.La serie incluye 85 casos de los cuales 42 se estudiaron intraoperatoriamente,de los cuales el 45,2% mostró positividadpara células tumorales. De los 43 restantes, estudiados en diferido,mostró positividad para células tumorales el 34,8%. En10 de los 85 casos (28,5%), el diagnóstico sólo pudo realizarsesobre los cortes teñidos con citoqueratina (CK). No se observarondiferencias estadísticamente significativas entre losresultados de los grupos intraoperatorio y diferido.En conclusión, nuestros resultados apoyan este protocolocomo un método sensible y específico que permite realizar eltratamiento quirúrgico del cáncer de mama y su estadificaciónen un solo tiempo(AU)

In spite that the Sentinel Node (SN) procedure is admittedfor routine breast cancer staging, there is still no agreementon the most efficient histopathological protocol to evaluate it.The main aim of this study is to describe our histopathologicalwork up comparing intraoperative and deferred protocols,and to emphasize the use of Cytokeratin Immunostain asa desirable part of it.Out of 85 cases in our series, 42 were studied by intraoperativeprocedure and 45.2% of them showed positive tumourcells. Of the 43 remaining cases, studied by deferred procedure,34.8% were positive for tumour cells. In 10 out of 85 cases(28.5%) the diagnosis was reached by cytokeratin immunostain.There were not statistically significant differencesbetween the intraoperative and the deferred groups.We conclude that the results make our method is sensibleand specific enough to allow one step surgical treatment andstaging of breast cancer(AU)

[Urinary calculi in myelomeningocele adults]. / Litiasis urinaria en adultos con mielomeningocele.

INTRODUCTION AND OBJECTIVES: The improvements in the management of newborns with myelomeningocele (MMC) have obtained a big increase in survival, allowing them to get longevity like never before, but data regarding urologic diseases during adult age are still missing. We herein evaluate the features of urinary lithiasis in adults born with MMC and the therapies used for its treatment. MATERIAL AND METHOD: We review 52 patients diagnosed at birth of MMC, between 18 and 40 years old, treated in our institution, with a mean follow-up of 6.7 years. RESULTS: 10 patients (19.2%) were diagnosed of urolithiasis. Three developed kidney calculi and one of them, with 7 more patients, developed bladder calculi (15.3%). The neurological level was < or = L2 in 3 cases, L2-S1 in 5, and > or = S1 in the other two. The type of neurogenic dysfunction of inferior urinary tract was multiple lesion of lower motor neurone in 6 cases, upper motor neurone in 1 case, multiple mixed lesion in 1 case and in case it was impossible to determine. Two patients had a bladder augmentation procedure and one of these with other 3 patients had a non-functional AMS-800 artificial urinary sphincter. Bladder stones were treated endoscopically in 14 procedures and by suprapubic cystolithotomy in 4 procedures, combined with removal of AMS-800 in 3 of them. One patient spontaneously passed a small stone. In one case, 2 ESWL and 2 percutaneous nephrolithotomies were needed. Three patients developed multiple recurrences during follow-up. CONCLUSIONS: Urinary lithiasis is common in adults with MMC. Some distinct features of these patients, together with their anatomical configuration and some therapies used in them, cause diagnostic, therapeutic and prophylaxis issues for the calculi they may develop.

Litiasis urinaria en adultos con mielomeningocele / Urinary calculi in myelomeningocele adults

Introducción y objetivos: Los avances en el tratamiento de los nacidos con mielomeningocele (MMC) han logrado un gran aumento en su supervivencia, permitiéndoles una longevidad nunca antes alcanzada, pero todavía son escasos los datos concernientes a los problemas urológicos que estos enfermos plantean durante su vida adulta. Hemos evaluado las características de la litiasis urinaria en adultos nacidos con MMC así como los tratamientos empleados en la misma. Material y métodos: Revisamos 52 pacientes nacidos con MMC de entre 18 y 40 años, atendidos durante los últimos 14 años en nuestro hospital, con una media de seguimiento de 6,7 años. Resultados: Se diagnosticaron de litiasis urinaria 10 pacientes (19,2%). Tres formaron cálculos renales (5,7%), y uno de ellos, junto con 7 pacientes más, desarrollaron cálculos vesicales (15,3%). El nivel neurológico fue ≤ L2 en 3 casos, L2- S1 en 5, y >= S1 en otros dos. El tipo de disfunción neurógena del tracto urinario inferior fue de lesión múltiple pura de neurona motora inferior en 6 casos, de neurona motora superior en 1, lesión múltiple mixta en otro, no pudiéndose valorar en el restante. Dos pacientes tenían una ampliación vesical y uno de estos junto con otros 3 pacientes era portador de AMS-800 no funcionantes. La litiasis vesical se trató endoscopicamente en 14 ocasiones y mediante cistolitotomía suprapúbica en 4, junto a la retirada de AMS-800 en 3 de ellas. Un paciente expulsó un pequeño cálculo. En un paciente fueron necesarias 2 litotricias extracorpóreas y 2 nefrolitotomías percutáneas. Tres pacientes tuvieron múltiples recidivas. Conclusiones: La litiasis urinaria es frecuente en los adultos con MMC. Determinadas características de estos pacientes, junto con su configuración anatómica y algunos tratamientos empleados en ellos, ocasionan problemas de diagnostico, tratamiento y prevención de los cálculos que forman

Introduction and objectives: the improvements in the management of newborns with myelomeningocele (MMC) have obtained a big increase in survival, allowing them to get longevity like never before, but data regarding urologic diseases during adult age are still missing. We herein evaluate the features of urinary lithiasis in adults born with MMC and the therapies used for its treatment. Material and method: we review 52 patients diagnosed at birth of MMC, between 18 and 40 years old, treated in our institution, with a mean follow-up of 6.7 years. Results: 10 patients (19.2%) were diagnosed of urolithiasis. Three developed kidney calculi and one of them, with 7 more patients, developed bladder calculi (15.3%). The neurological level was >= L2 in 3 cases, L2-S1 in 5, and >= S1 in the other two. The type of neurogenic dysfunction of inferior urinary tract was multiple lesion of lower motor neurone in 6 cases, upper motor neurone in 1 case, multiple mixed lesion in 1 case and in case it was impossible to determine. Two patients had a bladder augmentation procedure and one of these with other 3 patients had a non-functional AMS-800 artificial urinary sphincter. Bladder stones were treated endoscopically in 14 procedures and by suprapubic cystolithotomy in 4 procedures, combined with removal of AMS-800 in 3 of them. One patient spontaneously passed a small stone. In one case, 2 ESWL and 2 percutaneous nephrolithotomies were needed. Three patients developed multiple recurrences during follow-up. Conclusions: urinary lithiasis is common in adults with MMC. Some distinct features of these patients, together with their anatomical configuration and some therapies used in them, cause diagnostic, therapeutic and prophylaxis issues for the calculi they may develop

[Evidence of occult systemic hypoperfussion in head injured patients. Preliminary study]. / Existencia de hipoperfusión oculta sistémica en el traumatismo craneoecefálico. Estudio preliminar

OBJECTIVES: To determine the correlation between blood lactic acid levels in the first 48 hours and outcome, in hemodynamically stable patients, with moderate or severe head injury (HI), and to investigate the risk factors associated with abnormal lactate levels. MATERIAL AND METHODS: A prospective observational study, in 210 adults patients with moderate or severe head injury. When the patients were hemodynamically stable, blood lactate concentrations were measured once on admission, twice daily during the first 2 days and once daily until lactate levels were normalized. The whole group 210 patients were divided into 2 groups. Group 1: (LA < 2.2 mmol/L) patients without occult hypoperfussion (OH), and group 2: (LA >or= 2.2 mmol/L) patients with OH. RESULTS: One hundred and fifteen patients (57.76%) were categorized as group 1, and 95 patients (45.24%) as group 2. In the univariate analysis of risk factors for blood lactate >or=2.2 mmol/L the following variables showed statistical significance: severity of the head injury measured by several scales [Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Revised Trauma Score (RTS) and Acute Physiology and Chronic Health Evaluation (APACHE) II], arterial hypotension, hypoxemia, anaemia, hyperglucemia, hypothermia, a greater incidence of norepinephrine infusion, and the higher percentage of type II lesions in the head computerized tomography at admission showed in the group 1 (53.91% vs. 38.94%) (p<0.03). In the multiple logistic regression analysis only two variables were risk independently associated with elevated blood lactate concentration: APACHE II in the first 24 hours: OR 1.12 (95% IC 1.06--1.196; p<0.0001) and the first 48-hours total fluid infusion volumes: OR 1.09 (95% IC 1.021,16; p < 0.0001). The infection rate (63.2% vs 47.8%, p=0.026), and length of ICU stay [mediana (percentil 25--75)] [13.29 (7.11--21.22) days vs. 8.78 (4.40--16.72) days; p<0.018] were significantly higher in patients with blood lactate >or=2.2 mmol/L (group 2). Although, the percentage of intracranial hypertension and mortality was higher in the group 2, there was no significant difference. In the multivariate analysis, the increase of blood lactate concentration, was not independently associated as a risk factor with studied complications. CONCLUSIONS: The presence of OH in patients with moderate or severe head injury, with postres uscitation arterial pressure, according to present recommendations, is associated with a more severe head injury, showed by APACHE II and the total fluid infusion volumes in the first 48 hours. OH in head injury increases the infection rate and length of ICU stay.

Existencia de hipoperfusión oculta sistémica en el traumatismo craneoencefálico. Estudio preliminar / Evidence of occult systemic hypoperfussion in head injured patients. Preliminary study

Objetivos. Investigar en pacientes con traumatismo craneoencefálico grave y moderado (TCE), hemodinámicamente estables, la relación entre los valores arteriales de ácido láctico (AL) en las primeras 48 horas con la evolución y complicaciones del TCE, y conocer qué factores de riesgo se relacionan con valores anormales de AL. Material y métodos. Estudio observacional, prospectivo, de cohorte, de 210 pacientes adultos con TCE grave y moderado. Conseguida la estabilización hemodinámica del paciente, se realizó una determinación basal de AL, que se repitió cada 12 horas durante las primeras 48 horas y, posteriormente, cada 24 horas hasta la normalización de los valores de AL. Los pacientes se clasificaron en dos grupos: Grupo 1 (AL = 2,2 mmol/L) con HO. Resultados. 115 pacientes (57,76%) se catalogaron como grupo 1, y 95 pacientes (45,24%) como grupo 2. En el análisis univariante de los factores de riesgo para AL >= 2,2 mmol/L mostraron significación estadística todos los índices generales de gravedad del TCE [Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Trauma Score Revisado (TSR) y Acute Physiology and Chronic Health Evaluation (APACHE) II], la hipotensión arterial, hipoxemia, anemia, hiper-glucemia, hipotermia y la mayor incidencia de administración de noradrenalina. Asimismo, en el grupo 1 se objetivó un mayor porcentaje en la TAC de ingreso de lesiones tipo II (53,91% vs. 38,94%) (p<0,03). En el análisis multivariante de regresión logística, sólo dos factores se asociaron de forma independiente a valores elevados de AL: APACHE II en las primeras 24 horas: OR 1,12 (IC 95% 1,06-1,196; p<0,0001) y volumen de líquidos total infundido en las primeras 48 horas: OR 1,09 (IC 95% 1,02-1,16; p<0,0001). El grupo 2 se asoció, con significación estadística, a una mayor tasa de infecciones(63,2% vs 47,8%, p=0,026), y al aumento de la estancia en UCI. [mediana (percentil 25-75)] [13,29 (7,11-21,22) días vs. 8,78 (4,40-16,72) días; p<0,018]. Aunque fue más alto el porcentaje de hipertensión intracraneal y mortalidad en el grupo 2, no se constató significación estadística. El aumento de AL, en el análisis multivariante, no se comportó como factor independiente de riesgo para las complicaciones estudiadas. Conclusiones. La existencia de HO en pacientes con TCE graves y moderados, con valores de presión arterial postreanimación según las recomendaciones actuales, se asocia a una mayor gravedad del TCE manifestada por el APACHE II y por el volumen de líquidos administrado en las primeras 48 horas. La HO en el TCE conlleva un aumento de la tasa de infecciones y de la estancia en UCI

Objectives. To determine the correlation between blood lactic acid levels in the first48 hours and outcome, in hemodynamically stable patients, with moderate or severe head injury (HI), and to investigate the risk factors associated with abnormal lactate levels. Material and methods. A prospective observational study, in 210 adults patients with moderate or severe head injury. When the patients were hemodynamically stable, blood lactate concentrations were measured once on admission, twice daily during the first 2 days and once daily until lactate levels were normalized. The whole group 210 patients were divided into 2 groups. Group 1: (LA = 2,2 mmol/L) patients with OH. Results. One hundred and fifteen patients (57,76%) were categorized as group 1, and 95 patients (45,24%) as group 2. In the univariate analysis of risk factors for blood lactate >= 2,2 mmol/L the following variables showed statistical significance: severity of the head injury measured by several scales [Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Revised Trauma Score (RTS) and Acute Physiology and Chronic Health Evaluation (APACHE) II], arterial hypotension, hypoxemia, anaemia, hyperglucemia, hypothermia, a greater incidence of norepinephrine infusion, and the higher percentage of type II lesions in the head computerized tomography at admission showed in the group 1 (53,91% vs. 38,94%) (p= 2,2 mmol/L (group 2). Although, the percentage of intracranial hypertension and mortality was higher in the group 2, there was no significant difference. In the multivariate analysis, the increase of blood lactate concentration, was not independently associated as a risk factor with studied complications. Conclusions. The presence of OH in patients with moderate or severe head injury, with postresuscitation arterial pressure, according to present recommendations, is associated with a more severe head injury, showed by APACHE II and the total fluid infusion volumes in the first 48 hours. OH in head injury increases the infection rate and length of ICU stay